Chapters Transcript Video Anorectal Manometry – Start to Finish Webinar Series (1/3) Review the related anatomy, the setup process and probe calibration, as well as proper technique to place an anorectal manometry probe. Hello and welcome. I'm John L. Schmidt, the marketing director here at diversity of health care, and I'll be your host today. Burst of Healthcare is excited to present our next webinar, Siri's anal rectal Manama tree from start to finish in today's topic. Is anatomy procedure set up Improper probe placement? I'd like to introduce our speaker for the Siri's Jason Baker. Jason is the co motility director and director of clinical research at Atrium Health in Charlotte, North Carolina. He's a frequent presenter at national and international annual scientific meetings, and very recently he was elected as a council member for the American Neuro Gastroenterology and Motility Society. Ah, few items before we begin this webinar is being recorded and will be uploaded to Diverse Attack University after the syriza's ended. Your microphones have been muted for the duration of the webinar, and if you have any questions, please send them at any time. The other questions box on your go to bob in our panel, and we will answer them during the questions and answer session. At the end, we'll do you our best to answer all of your questions. And for those individuals that did not get their questions addressed or will respond to your question. Once the webinar is over, I'll now turn it over to Jason. Thank you for joining us today. We appreciate it. Um, you know, trying to find my slides here. There we are. All right. So the title for this webinar webinar one dealing with an erectile Manama tree is basically just anatomy review of why we performing Erectile Manama TRIA set up process. Proper placement technique more from a partnership between Allied health professional and the patient itself. So as we go through the anatomy review of the next few slides, it's all gonna based on the focal point of an erectile Manama tree. So some objectives were gonna describe that anatomy of defecation is very complex and then erected Manama trees allowed thio break it down piece by piece to try to find some some stuff that may be working above or lower than normal thresholds. To find out reasons why people may be having trouble with defecation we're gonna describe to set up for anal, recommend Manama tree the art of the proper Manama tree pra placement and then some techniques for developing a partnership between the allied health professional and the patient especially. This is a very important point, for this is a very invasive test. Is, you know, somewhat a very embarrassing. So this partnership between the allied health person and the patient is very important, as is we talked about the esophageal webinars, but this one has a little bit of different spin just because of the invasiveness of it all. So some anatomy, basically the indirect of Manama tree, is we look at a couple different muscles the internal anal sphincter, Um, the external anal sphincter in the pubis reptiles. So, as you see on this diagram on the right, the internal sphincter muscle, the one on the inner side here, I would say the one with a little bit of ah, thicker sweater per se, um, is mostly deal with resting tone. It deals with, you know, your body is smooth muscle kind of controls that self every response to stimulation, either by inflating a balloon, um, or stool coming down or finger digital rectal examinations or digital stimulation for people have to use a digital stimulation for Obama. All kind of re can't get stimulated in that internal anal sphincter. The external anal thinker. This is the one that's more skeletal. Muscle more. You have more control over the thicker muscle. Uh, sweater looking muscle here, and this is basically where you're allowed. Increases pressure as you squeeze or you're trying to hold from going to the bathroom. It decreases in relaxation. If it's having a normal, difficult terry maneuver, Um, it responds to the abdominal. Also, contraction kind of squeezes off or a cough reflex or and giggle. This is the one that kind of pinches off Thio, not allowing anything to emanate from the rectum out of the of the day. No canal out of your body, The people Shrek tell us. It's kind of a muscle. It's a sling muscle kind of wraps around here you don't really see. It wraps around a little bit. Posterior li see kind of depicted by just the muscle here, but kind of wraps around. This is the one who maintains continence for you when it's when you're not going to bathroom. We kind of have this this formation like this kind of pinching it off. But when you basically when you when you start to have this defecate defecation maneuver or mechanics. This this muscle will relax, then in Okinawa will become more straighter, they say obtuse. So the role of this people's reptiles, which is really important, as you see here on the left side, where someone's holding or trying not to go to the bathroom like you're in a meeting or you're watching a webinar right now that this people's reptiles muscle is kind of really pinch, you could kind of see it pinching it off, not allowing anything from inside this rectum to move beyond that line identity into the anal canal. So it's really squeezing off right there, and both muscles, internal external sphincter muscles tend to be contracted, But when you start to initiate the defecation mechanics, you see the force from the abdominal cavity pushing down. As you see this, the stool starts to creep back. Beyond that line, I didn't take into the canal. The pubis reptiles will start to relax. And as you see how this angle is, um, a large, uh, smaller degree, this one becomes a larger degree and you see it gets a little bit more straighter that up to then, as the force of this abdominal pressure pushes down, this stool eventually make its way out. As you see a diagram see for completion this evening gets a little bit more relaxed for more stool to be pushed out into the toilet. So, overall defecation mechanics. Do you suppose that up here in this quadrant, up here for resting again? When you're resting, you got this. People's reptiles. It's kind of squeezing external muscle. Sphincter muscles tend to be a little bit more contracted, and the internal anal sphincter tends to be a little bit relaxed. Then a normal defecation. Again, the pubis reptiles will start to relax. The force from the abdominal cavity starts to push down. There is a transit. Increasing pressure of the external figure will tend to toe contract real quick and relax become much more compliant. The internal anal sphincter will become much more compliant. Allow still to move into the anal canal that has more push. As you press down or bear down, more force will come out on. The stool will be removed. But with incontinence issues, there's a couple different things that could be happening. And this is sorry this is 11 of the main reasons we do interrupted Manama, tree is that the people's reptiles could be lax, so it's allowing stuff. Thio continues to emanate into the anal canal, and then you don't have the externally. I don't think your muscle could be, um, weekend. So if you're not allowing, have that last line of defense and then still will voluntarily be eliminated out of the body, um, diarrhea tape thing, same thing you could kind of loosen through here. And then you don't have enough of the external sphincter muscle to contract, Um, then with Justin urging defecation, it's a little bit of opposite of this instead of being lax is, maybe the pubic structures tells muscle gets more contracted as you think you're trying to eliminate Stool. Um, the external sphincter muscle could paradoxical contract that you think you're actually relaxing, but it's squeezing, and there's different values. As we walked through this woman arable give you these different percentages, or there could be just an inadequate amount of abdominal force moving down to push the stool through the rectum into they know, canal in out of the body. So most of time. These these two down here, there's a combination just not just one of these, but a combination of these causing either the incontinence or the distant, urgent defecation. There's nerve innovation, Um, that occurs and a couple of different ways. We can assess this in, uh interrupted Manama tree, but there's there's the nerve that comes down from the brain down through the spinal cord. Easy gets out of this, uh, sacred two through four or offices and kind of innovates or with the external sphincter muscle inside inside the anal canal. And then, basically a lot of it could be the potential nerve is the primary one, So that is the one that's basically, if stool comes through that, um in today no canal, that nerve innovation will basically have the external sphincter muscle contract, hopefully keeping your continent and not incontinent. But as time, that's one way we can assess. If for continous, you sustenance. Put on on your muscle. Um, there's a simple way you could do with a Q tip. If you just tap a little bit of right around the opening with the back end of a Q tip, you should see this thing called the Anal Link. It would be really quick. The muscle will kind of contract. Maybe one way of ah poor man's way Basically assessing that nerve innovation. But before you do any indirect in Manama, tree is very important to do the digital rectal exam. And there's a proper protocol doing this and this is really important to tell you a lot of different things As you start dating director Manama tree the first step, You know, you just kind of want to assess the area, you know? I mean, you wanna you Can you just wanna ask them to squeeze? You should see the Paranal cap. You see, the be squeezed in. You see the muscles kinda move kind of tighten up then when you wanna ask them basically thio try to defecate and then or simulate defecation You can see you should see it normally start to relax But then after that you wanna put you see you see, on the right hand side you're gonna put your introduce your finger lubricated quite well, and you're gonna kind of wrote Follow that post eerily and you want to get above this pubis reptiles, you kinda you kinda feel it if you just have them say can you try toe like a squeeze. You kind of feel a tug and you'll know you're quite there. But you wanna ask him to basically squeezed. I mean, trying to hold it in. Don't let anything out. You wanna ask them to try to, like, try to have a bowel movement? Um, like, bear down. Try to have a bowel movement to see if this muscle right here relaxes. And also the external sphincter muscle type to relax. It also allows you to know they understand what you're asking them to do during the director. Manama tree. Um, third step, you want to kind of help it just to see if there's any sensitivity there, Then the last step You wanna put your hand on the abdominal cavity and ask them again to basically try toe like you're trying to have a bowel movement? You must. You wanna basically qualitatively feel if they're producing enough abdominal force. Thio have have a bowel movement. So the major indications for indirect Manama tree are really fourfold. There's constipation and continents. Um, pediatric, most of the world of her spring disease. We won't get too much into that. Then a lot of people do preoperative colorectal surgery and or for a no pain or any other type of colorectal surgery, you may want to dio interrupted Manama Tree, but the top two by far constant chronic constipation and fecal contents. It's a little bit about constipation. There's a you know, global prevalence up to 18%. Most of the literature shows that it's primarily 2 to 1. For female to male, it tends to increase with age. Um, um, then dishonor. Justification is basically that paradoxical. Contraction will walk through exactly what this is in a little bit, um, is detected in about up to 60% of people who do have chronic constipation, especially the ones who fail empirical active therapy. So a little bit about the pacifist of fecal contents. You know it Z fecal incontinence. You could be chronically constipated and still be fecal contents, so it's a little bit of a Venn diagram. It could be due to structural abnormalities. It could be due to functional things stool characteristics. So taking a good history allows you to have a big, better image. What exactly is going on, especially in this very comprehensive thing of fecal incontinence? But only about 3% of providers actually asked about fecal incontinence and an inpatient setting. But despite that, 51% of patients experienced some fecal contents, so you may be the first line everybody has ever asked about it. So, um, be open to that conversation. Definitely want to control the room during that conversation because the conversations could get a little bit long. But you may be the first person to even ask about it, especially it's a very embarrassing thing. Andi, I would say this. My experience holds true in the male population. The males and females tend to have a little bit of different reason why they have in continents. So if you look on the left hand side for males like 63% there is generally no sphincter abnormality during interrupted Manama tree, causing the fecal contents or at least contributing to it. Um, and then up to 19% or one of every five has a combination of basically internal anal sphincter and external anal sphincter. So compared to females, you look over here. Only about 25 23% have no sphincter abnormality, and it generally in the female world there's a combination, or at least isolated one of the other for external sphincter or internal anal sphincter abnormalities, causing the content so difference between males and females. So we'll get any questions so far about this anatomy before we move onto the set up of the interrupting Manama tree. Okay, but if you have any questions, we can definitely come back to that Azzawi, move on through the webinar. So how did set up is really important for an erection ometer especially. I really believe it's setting up because you want when the patient comes in the room, you really wanna be solely focused on them and not setting up at the same time and trying to have this conversation. I think this is a little bit different than the esophageal world because you kinda sometimes do both. But in this world being a little bit more invasives, definitely more embarrassing. And sometimes it takes a long time for people to even ride, so have uninterrupted Manama tree. Is that, um you wanna have everything set up so you can solely focus on them as they come into the room. But some supplies that you want to 60 ml syringe. You need some lubricant. I would say have more than you need. Just in case, Uh, you never know how much you're gonna need depending on, um, you know, the patient comfort ability. You want some gauze tape in a three way Stop cut. So the first step because, you see, we're gonna start in putting the patients starting information on the right hand side, you'll see the software itself. You have a bunch of different options. Most of them will be disabled in erectile slash hrm, which is high resolution and erected. Manama Tree will be enabled, and this is where we're going to start. This is called bio View Analysis. We're gonna walk through this, and this is the beginning stage of the window where basically we're a selective program. Calibrate the version of the calibration, then, uh, putting the patient information. It's easy to follow. Software prompts you through step by step. Um, so it's really well done to walk you through this. So the set up process on the left hand side will be the first screen will come beyond. After the face screen, you have three different options procedure patient rectors, options, or go back. We're going to select procedures. Then the next window comes up is the one on the right. And you may have depending on what catheter you may have. Um, that type of thing. You may have several of these, as you see on the right hand side that has several different catheter options. But you or you may just have one. Is So you want to select the correct protocol right now selected for high resolution, uh, interrupted Manama tree. Then the D f. You selected the pro. The details protocol details will show up. You won't have to do anything in this window. Then if you're If you're okay with both of these to move forward with this select. Okay. The next window pops up again. It gives you a couple different options. Calibrate start new patient or start existing patient. Um, I would say start existing patient. Say one thing here. I don't believe in, like, pre calibrating thing. So I would say this one I would barely ever use so kinda, but either calibrate. Then start new patients. Stay in that order. Um, that will definitely help you stay in sequence throughout the entire test. Um, then on the next right hand side after you hit Calibrate, you're gonna get the calibration window. You're gonna You're gonna have start pressure calibration Skip it and back. You always want to calibrate during before any procedure. Um, it's protocol, and it basically sets up the Catholic. Make sure you have the Catholic is working properly, so I would say a similar to start existing patient I would stay away from skipping pressure calibration. You have two options. You have one with millimeters of mercury. You have one with water displacement. Another time ago, when I first started doing this 20 some years ago, we did some of this water displacement calibration moving forward and for probably the last 15 or so years, we don't usually use it. We don't have not used that option, so they're always going to select 100 millimeters mercury or pressure, and then you're gonna hit start pressure calibration. Then, um, there's you'll see. It'll walk you through about when the calibrate the catheter and then as webinar two and three. Well, we'll show you some screen images about what does images look like when you calibrate the catheter on how to know it's calibrated correctly. The next Windows is set up process and there's a bunch of different form line items that you may want to input, but the only ones that require the ones with the Asterix. But I would I would highly suggest you fill in all these in. It will help make the report look a little nicer and also allow you to organize your test a little bit better than if you ever have to look the test back up in the as time goes on. You a lot of this information that you may need already be there. Then after you fill all these in your going to select. Okay, So the equipment set up for the calibration for high resolution Manama tree there's gonna be a little bit difference between the high resolution and the disposable, the calibration, um always calibrate for each procedure. Very, very important. You're gonna have that stop cock. You're gonna put on tight tight on the infusion port because you need that infusion port to be closed off from the ambient air. Basically the air in the room. You don't want that on, then you don't want also the pressure calibration to leak out. Um, calibrations perform always using millimeters Murkier pressure. We're gonna set the standards for the transducers, then, um, zero. Then we're gonna pump it up to one volume up, 200 millimeters of mercury pressure on. Then we're gonna hit safe. Then then we're gonna do a test one. You're gonna pressure pump it up again to 100 millimeters of mercury pressure. Make sure all the channels move up to that level. This the validated, the following the validation of that, we're gonna take it out of the chamber. Then that's when you're gonna tie the balloon onto the distal end, either with future ORF loss. I would, you know, when you're trying to balloon on for high resolution, I would I would recommend flaws over future if possible. Because when you type flops on at the end, when you're pulling it off, you could take a little bit of a wet cloth and just kind of pull on in the in. The floss itself will get a little bit loosen to help you snip the balloon suit, floss off and pull it off a little bit easier than the future. The future tends a little bit a little bit more challenging, but after you tied on. You're always gonna put a little bit of, like, 30 ccs of air in there just to check to see if the balloon is holding volume. So the equipment set up for the disposable catheter, So a little bit different? Um, first thing, I'm gonna connect the probe to the stem sense. Bronx is an apparatus thio based on different type of probes that allows us to measure the pressure in the balloon. The disposable catheters are connected to this thing called a legacy adapter is kind of like a manifold type of thing. It's gonna be connected on the right, left and your posterior, and this connects to the ultimate prison system again attached a three way stop packed to the infusion port on the probe. When you're calibrating this one, you won't have to tie a balloon onto it to Bloom is already connected for you. So this is the catheter itself, for this is the high resolution. The Manama tree catheter is that these are This is the distal end. These air, the censors itself. Um, this is the reference sensor. This black one, right? This line right here will allow you shows you When we insert the catheter in the body, we're gonna go up to this depth. Um, and then it's just the balloon will be tied onto this. This Andrey here where you with the floss or suit yourself. So some procedure homework, which I think is really important, as if we talked about in the South of Geo Manama Tree webinars. Pre procedure homework is very important, especially for the invasiveness of the tests that you wanted a lot of information. If you can, you can offer we all every place I've been. We also have this as if you order these tests from outside people. These are some of the things that we require to be sent over with the referral self. What symptomology do they feel pain? They feel bloated. That type of abdominal pain, Um, that type of things that deals with either they're defecation issues. We want to know if they're constipated. Maybe for how long? If there was a Genesis point, maybe it's idiopathic, and they're not sure when it actually started. What did it happen after an accident that after childbirth incontinent same type thing? When did it happen? Um doesn't happen more often in college, you could start asking if it's do it. Stool continents, liquid and continents, mucus and continents, gas and continents is combination of all those, um, is a conservation of fecal incontinence. This is a big one right here, because people will come in and you see the diagnosis vehicle contact, you know, find out just by your review of their past medical history or just a conversation itself. They really they really experience a lot of chronic constipation, but they have incontinence through the constipation. So maybe a little bit overflow constipation, anal pain, especially with men. I would ask about that then abdominal pain itself if they've had any previous colorectal surgeries. Hemorrhoid ectomy, Ziff. They experience rectal prolapse. If they've had anal fissures, these type of things, you definitely wanna inquired with females about public floor injuries. Uh, men with accidents like sporting accidents or any type of thing like that previous birth history. Vaginal. How many Sikhs section? How many did they have? An episiotomy with the vaginal deliveries? If so, how many? That type of thing and any other variables that are comb abilities are a priority variables to deal with defecation. I would highly encourage, uh, enquiring about those prior during your pre procedure homework and then also fill the blanks in as your conversation occurs with them. So another. Within the colonoscopy report, you won't know if there's any obstructions down there president of structures or narrowing in the rectal signal region. This will also help as you're pushing the catheter in. If you're getting some regurgitation, is why that may be or as your finger goes and it's not going in as easily or comfortably as, Um then normally you kind of want to know what's Anaconda asked me if they found a signal. It asked me if they found anything. Um, if they've had a death, photography, barium or m r I beforehand, it's really important to read the report. And if they have a video little clip you can watch, it shows you to shape the coordination of the indirect, um, almost like the SA program. As you're putting this on video. Manama Tree Catherine The death photography just in a different region will show you the shape and coordination, and it really tells you what's kind of what's going on This pupils tracked Alice angle, um uh, during that. So you kind of have an idea. What? What may, when you're doing an erect Manama tree? Are they understanding your explanation of the tests? Are there just in discord in communication with you? Here's some different story images, de photography images that you see on the left hand side when someone squeezing you see this angle right here is much smaller. Receipt is tightening off on all. The barium contrast is basically in the wrecked in the rectum. But when someone basically strain is based, simulate defecation, you see the angle get much larger and Daniel Canal get, you see, get straighter. And then, as they push down or bear down, they'll basically this Barry and will start to be removed from the anal canal out of their body. So these are some of the images. If you have access to them, I would take a look at him and get more familiar with them as time goes on. But one thing up here, like straining as you're seeing, bear down similarly defecation. It's really important Thio to use the same terminology, but you'll notice as different people will use different things. But this is make sure you understand that this straining all these other term in terms are all referring to the same maneuver. You want to prepare the patient, It's really important. You wanna know? They give them a very brief explanation, but very concise. What? The purpose of the test. Why we actually, they're doing this because it takes sometimes it's gonna take a lot long time for someone. Actually, Thio come in for the test itself. So you want to give them why we're doing that? The tests, like we're gonna basically the of the what I tend to say is that the defecation mechanics is very complicated and complex. And this test right here, it's, you know, less than 20 minutes, but we'll be able to break down the defecation. Mechanics basically step by step to see if we're inside the sequence. May or may not be working, um, in a in a normal coordination pattern. So something like that, Very something. Very similar symptoms. So they have an idea what? It's gonna be gonna be occurring? Um, pre test preparation, you know, tap water. Animas, um is what most people use. We try, They highly recommend these people try to do it at home a couple hours prior to coming because of the you know, sometimes it takes a little bit of time. Often they're more comfortable if their spouse or partner or themselves doing it instead of you know, something else going in their body, Um, in that region, in at the clinic or lab. So we highly recommend that, But you may You may need to do that, um, in your clinic or lab, just depending on, you know, different capabilities of the patient, the approximate length of the procedure. I always say the length of the scheduled time is about 60 minutes, but the length of the procedure itself is about 20 minutes, so that tends to calm them down a little bit more that they know the test is not gonna last 60 minutes. Sensation you're likely going to experience. I always say, you know, it's gonna be very similar to when you're when you're having that feeling, to have a ball movement very similar to that. The risk of the procedure, we give them the risks and the common risk of the procedure, you know, And that's a little bit different. I would check with your home base, Uh, about that. But generally, the three that we use for risk of procedures are discomfort bleeding in an preparation because something's going in their body. But all these are very, very low risk. Uncommonly experience, Um, medications. Some people hold different medications, it's more sites, site difference. Check back with your team to figure out which type of medications you may want to withhold from before the procedures. And mostly like the pain medicines and in particular, so proper placement technique. After you get the patient, you wanna have them get undress from the waist down, you're gonna have a gown where the ties in the back doesn't really need to be tied. Um, you're gonna put the patient as they lay on the back, Then they're gonna roll into their left side, and then you're gonna bring the knees and hips approximately 90 degrees, but we always adjust. Asked about during the pre procedure homer, if it's not in there, we always ask in regards that they've had a knee, hip or back surgeries prior to get them into this 90 degrees, you may not be able to they may not be able to get to that degree. So you wanna just for that if needed. Um so the so the catheter itself going back to the high resolution Manama tree catheter, Um, has a black posterior line so that that's the line that's gonna line up in the posterior position or towards the spine. So if you want to orientate the catheter where that black line in the spine are basically are parallel with each other, you're gonna lubricate the probe you can lubricated liberally. Then you're gonna for the higher H r A m, which is high resolution. Indirectly. Manama Tree. You're gonna insert the catheter about 10 centimeters past the balloon to that reference line that be demarcated on that particular slide. Um, for disposable catheters, it goes in about 10 centimeters. Um, again you'll see. You'll see a 10 7. You're marking on the catheter. But there's a little bit different positioning here. Is that basically when you get the high resolution one in, they're going to take a baseline pressure in the in the rectum. But then you're gonna pull it back until where you see the pressure, the anal sphincter, external sphincter band of pressure, Um, in the middle of type of the screen will show you some images like that. Then it disposable one. You're gonna have to do a pull through technique to figure out eventually the the sentiment of depth. You're going to place that. Um, Then again, you know, we talked about the interactive baseline. Then you're gonna just a catheter to isolate both those muscles. Any questions? S o far before we move on some some pearls toe for the Allied health professional in the patient. Thio Partnership plan. Jason, there's a question of their basic question on, uh, rectal exam. Um, one of the audience members understands the concept of diminished tone. However, how do you define the heightened tone on an anal exam at baseline that may prompt you to send them for testing? Good question. So its qualitative for sure, this I kind of define is this If I feel if I have my if I'm doing the rectal exam and I feel like a the significant around pressure around the base of my index finger, I would say I would say that would be a hyper more, a little more hypertensive, But if I I asked him to squeeze. And there's barely no difference around based on my index finger. Um, that would be a little bit more hypotensive, and I would, I would. But I think and then if that's the criteria that I would send them but for, um, for diagnostic testing. But even the hypertensive one, I would say there's some use for indirect Manama tree for that particular person also, but it's a qualitative thing, and there's really no value per se. But it's more qualitative. And I think the more that you dio, the more that you'll you'll. You'll have a gauge on your own finger what that may be. And I think that gauge is different from person to person. The literature has shown that a little bit. When multiple people do the rectal exam on the same person, the results could be different. All right. Good question. A good question. Um, so a little bit pearls for Allied health professionals and patient partnership. Um, this is this is becomes really important. I believe in this test. I think you can You can win or lose the room really quickly. Always when I'm teaching this always taken, win the room and lose the room in the first two minutes. And, um especially if there's a male that is gonna be performing the test on a female are you know, you know, um, female, the male this could be could be things there. There could be an embarrassing factor there. You know, patients may have never really expressed this to anybody. Um, all these type of things could play, play a role in here. So, um, dealing with an anxious patient Most time they're anxious for a different reason than Asafa Geum or anxious and the embarrassment factor and the most primary. The most embarrassing question you you'll get often is that they don't wanna have a ball movement on on the bed. So it's really important that if they do ask that you encourage them that, you know, um, that happens. It does happen. But there for this particular test say, um, don't do not worry about it, that it could be expected, that trying to put them the ease that that that could occur. And they're not the only one that this is gonna happen to. And like I said in the previous slides, a couple slides back. Is that that this may be the first time they've ever expressed it. Never opened up to these type of issues. So actively listening is gonna be a really important thing. Knowing when the comfortable and respectfully kinda navigate the conversation without basically cutting them off is an art in itself. And unfortunately, sometimes people will come into your lab for this particular test that that maybe had some abuse in their past. So be very comfortable. Allow them the act, being active listener as they express themselves. If they do end up opening up, um, then the talkback method. Um, if anybody's ever heard me speak before, always, I'm a big person. Believe on the talk back method. After you explain the test to them and what's gonna happen and really settle them down just a little bit, you want them to explain it back to you and try to get, like, two or three sentences back to what you said to them that they could put it in their own terms and say it back to you. And this tends to definitely decrease anxiety if they're able to explain it back to you and some of this you, maybe you may allow them Thio, Listen thio their iPhone or android with an iPod, uh, pot in their ear. As long as you know the one here, they can hear and they follow the instructions. Um ipads. Or if you have TVs in the room, you could set the room up. All that's okay as long as they As long as that they pay attention and perform the test. And when you ask when you instruct them to do different things during the test, I'm a big believer. I don't tell the patient that relaxed similar into the Sava Geo World Interactive world. You know, because more you tell someone to relax and it's gonna be definitely more challenging to get them to relax is they want they they may feel like you're getting a little frustrated. So I would just come up with different strategies about the relaxation, productive strategies. It could just be about having a conversation. Ah, common thing, um, asked them about maybe what they're listening on their music or some of that nature. But definitely, I would say, Stay away from saying Please relax. You want to read their body language, especially these these these patients. They tend to be a little bit more. Um, you know, restrictive type of thing. Eso you wanna, you know, basically ascertain the stress level by just reading your body language. Um, you wanna be empathetic, And if you ever had this test on you participate in research studies or you or you just have the test done for diagnostic reasons. But if you're not, you wanna be empathetic that, you know, something is going into, um, transitional Lee, That is embarrassing. Maybe something never been up that they're itself. So you wanna be empathetic? Thio test itself. So in summary, basically the physiology and anatomy associated with defecation is is complex. There's many different things that indirect Manama tree were able to assess lower normal thresholds or above upper level normal thresholds individually throughout the test. So to see, maybe we're stuff or many things. Maybe, um, paradoxically or discordant to why they're having defecation issues. Accurate placement of the interactive in Africa is pivotal, especially for high quality test again, that reference line post eerily if it's flipped over, I mean, the orientation to the software obviously is gonna be flipped the UN's orientation. So you wanna make sure you placed a catheter correctly, then the partnership technique between patient and the provider herself definitely impacts results and patient compliance and decreases anxiety. So for robbing our one week, this will end here well, as weapon or two and three will walk through different things of a normal studies on abnormal things that measurements, um, for both the high resolution in the in the conventional catheter based ones. But I appreciate everybody's attention today, and I'm happy to answer any questions anybody may have. All right, um, between inflating the balloon with air or water, which one would you recommend on the catheter? Um, during the test, or are you like to check the balloon is, um, is suited on correctly. I'll say definitely for the one. If the balloonist the check for the balloonists featured on correctly, I would use air. Um, then during the test, I would also probably suggest air. But if after a directive Manama tree, there's another test you can do. Also during that, Why the patients their balloon expulsion test and then that one I would definitely use 50 mls of room temperature water. Okay, um, can a patient tank anxiety all attacks before the test? I'm not sure if I pronounce that correctly. It sounds like take a little bit of anxiety off. Yeah, we've We've done that. We don't encourage that. But sometimes for a multitude of reasons, someone may need that. I would suggest if you if you do prescribe that prior to the test, if they would do it, um, to, uh, two hours prior to the test and also, um, you know, have someone drive them especially. I think that's part of the requirements that medication, but had them someone driving. But as long as they take a two hours prior, the Manama tree results won't be, um, impacted. Good question. That's a good question. And I think especially in this world, you may get that question more often than the South of Geo world. Um, I think that is all that we have for questions. Well, if anybody has any questions, we can, you know we can We can address them on webinar two and three. Um, we'll get more into the tracings and the images and the different measurements and those two webinars, Um, but this was more of the set up towards that one, but it's really important to understand the anatomy. I think it will give you a better idea of to proper placement comparability of the test. Higher quality of the test, um, understanding the catheter itself on Ben. Also practicing different techniques and partnership. We're all playing a role they produce. Ah, higher rigor of a test. Especially as we look at Webinar two and three from the high resolution to the conventional catheters. I really appreciate everybody's time. I hope everybody stays well out there and we look forward in the next couple weeks for webinar two and three. Thank you, Jason. Well, this concludes our webinar anatomy procedure set up in proper probe placement. Please join us next week on December 10th from 4 to 5 p.m. Central time for the next webinar in the Siri's where we cover exploring high resolution in Iraq to Manama Tree. Thank you and good night. Created by
